Nakao mesenteric approach in pancreatoduodenectomy for pancreatic head cancer

Isolated pancreatectomy using mesenteric approach

In 1981, we developed the first antithrombogenic bypass catheter for the portal system. This catheter‐bypass procedure relieved the time limitation caused by portal occlusion and facilitated safe and easy resection and reconstruction of the portal vein or hepatic artery. We thereafter explored isolated pancreatoduodenectomy, in which pancreatoduodenectomy is performed under non‐touch isolation techniques. It is difficult to perform isolated pancreatoduodenectomy because of the complex arterial anatomy of the peripancreatic head region. In 1992, a mesenteric approach was developed for pancreatoduodenectomy. This approach allows dissection from the non‐cancerous side and determination of both cancer‐free margins and resectability followed by systematic lymphadenectomy around the superior mesenteric artery. This approach also enables early ligation of the inferior pancreatoduodenal artery and dorsal pancreatic artery branches from the superior mesenteric artery, as well as complete excision of the total mesopancreas (which is thought to be the second portion of the pancreatic head nerve plexus). Through this development of the mesenteric approach and antithrombogenic catheter‐bypass procedure, our isolated pancreatoduodenectomy was finally established in 1992. This is the ideal surgery for pancreatic head cancer from both surgical and oncological aspects. We herein introduce the precise surgical techniques.

Controlling the arterial supply into the pancreatic head region as a whole peripancreatic arterial arcade via a mesenteric approach during isolated pancreatoduodenectomy

PURPOSE

The peripancreatic arterial system forms various arterial arcades and collateral branches; therefore, it stands to reason that the arterial supply into the pancreatic head region should be controlled as a whole peripancreatic arterial arcade rather than as the three major supplying arteries during isolated pancreatoduodenectomy (PD). We investigated the clinical importance of early control of the whole peripancreatic arterial arcade during PD.

METHODS

The subjects of this retrospective study were 63 consecutive patients who underwent PD via a mesenteric approach at our hospital between October, 2014 and February, 2017. The patients were divided into an early control group (n = 27) and a late control group (n = 36) for comparative analysis.

RESULTS

The peripancreatic arterial arcades and collateral branches were seen on preoperative multidetector row computed tomography (CT) images and during PD in all 63 patients. The early control group had significantly less intraoperative blood loss than the late control group. Early control of the whole peripancreatic arterial arcade was an independent factor associated with lower intraoperative blood loss in the multivariable analysis (P = 0.012).

CONCLUSION

The arterial supply into the pancreatic head region should be controlled as a whole peripancreatic arterial arcade rather than as the three major supplying arteries during isolated PD.